Jan 16, 2024

New Shared Standards for Suicide Prevention and Intervention Show Results for Providers

Last spring the MN Health Collaborative announced a new set of evidence-based recommendations for suicide prevention and intervention in Emergency Departments. These standards, adapted by work groups consisting of physicians and other leaders from Emergency Departments and psychiatry, are rooted in the mix of combined experience of MN Health Collaborative’s members, shared learnings about tools and current or planned practices in use, and review of existing relevant literature.

The Collaborative established this initiative as a response to the clearly increased need in mental health care treatment at all levels of care, but especially the medical “front line” of emergency medicine. According to the Centers for Disease Control and Prevention and National Center for Health Statistics, in Minnesota, the suicide rate increased by 40.6% in the past decade and visits to the Emergency Department for mental health and substance abuse increased by 75% in the last seven years¹. On a national scale, nearly 45,000 people died of suicide in 2016, and more than half were not diagnosed with a mental health condition².

The Emergency Department is a critical place to identify people at suicide risk and provide support. Approximately 8% of all adults visiting the Emergency Department report suicidal thoughts³, including those who visit the Emergency Department for non-psychiatric reasons. The time after Emergency Department discharge is one of high risk for patients seen for suicidal thoughts or behaviors. Within one year following their visit, the risk of suicide for these patients can be 66 times higher than that of the general population⁶, but there is often poor follow-up care. Furthermore, 40% of patients who died by suicide visited an Emergency Department within 12 months of their death^4,5. A large population study in 2018 revealed approximately 70% of patients at risk of suicide did not have an outpatient visit within 30 days of Emergency Department discharge⁷.

The evidence-based, new shared standards provide recommendations on screening, assessment and intervention and transitions and follow-up care. The recommendations are as follows.

• Determine Population

Using one of two approaches, organizations should determine patient populations to screen for suicide risk. These approaches are either targeted screening for specific patient populations where risk is known to be higher, such as people who present with an acute mental health need or have a mental health disorder diagnosis, or universal screening of all patients who present in the Emergency Department. The approach used can be decided by the organization based on their patient population and the resources the organization has available.

• Screen Patients

The MN Health Collaborative standards recommend using an evidence-based tool to screen for suicide risk, such as the Columbia-Suicide Severity Rating Scale for children (5 years and older), adolescent and adult patients, or for patients ages 10 to 24, the Ask Suicide-Screening Questions which can be especially relevant to pediatric populations. The shared standards recommend screening be conducted as early in the Emergency Department visit as possible, including triage, and having patients self-report via a questionnaire, which may elicit more honest responses.

• Conduct Risk Stratification

The shared standards encourage organizations to conduct risk stratification to determine Emergency Department rooming and resource needs. Generally, the standards include using the least restrictive interventions and setting for any risk level. This stratification may make it easier for organizations to decide safety precautions like rooming, clothing, sitter needs or video/audio monitoring. Not every patient needs high-risk precautions, which can be unnecessarily resource-intensive and sometimes counterproductive if implemented across the board.

• Assess and Intervene

If screening indicates suicide risk, comprehensive assessment and intervention are needed. The shared standards recommend using an evidence-based tool or protocol for clinical assessment and provide evidence-based interventions. The MN Health Collaborative suggests a number of such tools when time or resources are limited, including Suicide Assessment Five-step Evaluation and Triage Interview, Safety Planning Intervention, Columbia-Suicide Severity Rating Scale Risk Assessment in conjunction with Safety Planning Intervention and training in Counseling Access to Lethal Means and Coping Long Term and the Active Suicide Program protocol. For in-depth assessment and intervention, the Collaborative suggests Linehan Risk Assessment and Management Protocol, Collaborative Assessment and Management of Suicide and Family Intervention for Suicide Prevention. The shared standards also include conducting follow-up contact for patients discharged to home or community.

• Decide Disposition

Disposition should be determined by the Emergency Department team alongside whoever conducts the full suicide assessment and intervention as a collaborative effort that also includes, whenever possible, the patient and their loved ones. The most common disposition options include continued Emergency Department observation, admission to an inpatient behavioral health unit or discharge home.

• Observe

Throughout observation during the Emergency Department visit, clinical reassessment and compassionate stabilization should continue. The MN Health Collaborative recommends Collaborative Assessment and Management of Suicidality as one tool to consider for recurring reassessment. If there is access to behavioral health services, these specialists provide assessment and intervention during the observation period. When there is limited or no access to behavioral health services, organizations are encouraged to connect with community organizations, local crisis teams and chaplains for additional support for patients with prolonged Emergency Department visits.

• Inpatient Admission

If the decision is made to admit a patient to an inpatient behavioral health unit, compassionate stabilization should continue until transfer is complete. This means labs should only be obtained when medically necessary. Emergency Department teams should collaborate with the behavioral health unit team to determine potential interventions while patients wait to be placed. As with the observation period, ongoing stabilization should occur.

• Discharge Home with Safety Plan

If the decision is made to discharge a patient home, the Emergency Department team should first conduct safety planning using a validated tool like the Safety Planning Intervention, if not already done. If patients cannot credibly commit to a safety plan the disposition to discharge should be reconsidered. Additionally, the Emergency Department should coordinate a follow-up appointment for the patient with either their primary care or outpatient behavioral health whenever possible, and provide a sheet with emergency crisis hotline numbers to the patient and family.

• Post-Discharge Follow-Up

Follow-up is always indicated since post-discharge is a high-risk time for patients. Follow-up may include:

• Bridging follow-up, a follow-up within 24 hours of discharge as a supportive bridge to their outpatient appointment
• Continued follow-up, phone calls to further review and enhance Safety Planning intervention
• Non-demand follow-up, a letter or postcard followed by a phone call expressing concern for the patient’s well-being

“We’re receiving many positive comments from provider Emergency Departments in Minnesota that have adopted the new standards,” said Tani Hemmila, Director, MN Health Collaborative. “Although the results are empirical at this point, we’re pleased with how quickly the providers have adopted the new screenings and it is clearly helping both mental health patients, and those that present for medical issues that may have underlying psychiatric conditions as well, get better care both during and after their visit to the ED.”

The full report and recommendations for the new MN Health Collaborative shared standards can be downloaded here.

References

1. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death on
   CDC WONDER Online Database: 1997-2017, released 2018.
2. Minnesota Department of Health. Suicide, Alcohol and Opioid Deaths in Minnesota. Alcohol and Other Drugs
   Quick Facts.
3. Centers for Disease Control and Prevention. Ten Leading Causes of Death and Injury. Data and Statistics
   (WISQARS Fatal and Nonfatal Injury). 2016.
4. Ilgen MA, Walton MA, Cunningham RM, et al. Recent suicidal ideation among patients in an inner city
   emergency department. Suicide Life Threat Behav. 2009;39:508-517.
5. Gairin I, House A, Owens D. Attendance at the accident and emergency department in the year before suicide:
   retrospective study. Br J Psychiatry. 2003 Jul;183:28-33.
6. Da Cruz D, Pearson A, Saini P, et al. Emergency department contact prior to suicide in mental health patients.
   Emerg Med J. 2011;28: 467-471. 12.
7. Hawton K, Witt KG, Salisbury TLT, et al. Psychosocial interventions following self-harm in adults: a systematic
   review and meta-analysis. Lancet Psychiatry. 2016;3:740–50